The doctors made me a new jaw from my shoulder - with ready fitted teeth
- From: J <nexsw@nvalid,anon>
- Date: Sat, 14 Apr 2007 05:58:05 -0400
<http://www.dailymail.co.uk/pages/live/articles/health/myoperation.html?in_article_id=441894&in_page_id=1989&in_a_source=>
The doctors made me a new jaw from my shoulder - with ready fitted teeth
By MARTYN HALLE - More by this author » Last updated at 15:46pm on 20th
March 2007
Cancer of the bone affects a few hundred people in Britain each year. When
it attacks the face or skull, major surgery is required.
Retired businessman Barry Giles, 69, from Ascot, Berkshire, had two-thirds
of his cancerous jawbone removed and replaced with part of his shoulder
blade. At the same time - a surgical first - a replacement set of teeth
was implanted. He tells MARTYN HALLE his story, while the surgeon explains
the procedure:
The first time I noticed something wrong with my mouth was in July 2005
and I was visiting my son in New York. It hurt when I chewed food and
worried me enough to see a dentist on my return. She took some X-rays and
didn't like what she saw. So, in October 2005, I was referred to an oral
and maxillofacial surgeon at my local hospital in Windsor.
He took a sample of tissue from the back of my jaw and sent it to a lab.
When I returned to see him, he said they'd found a tumour, but it appeared
to be a benign ossifying fibroma. To remove it would involve major
surgery, so it was decided to monitor it. Over the next three months, the
soreness became painful and I could feel a swelling at the back of my jaw,
so I went back to the surgeon in January 2006.
He sent off the original biopsy to the Nuffield Hospital in Oxford for a
second opinion. Back came the reply that what had been thought to be a
harmless growth was, in fact, a malignant tumour. I was shocked. When I
told a golfing friend, he recommended I contact the oral and maxillofacial
surgeon Iain Hutchison, who operates at Bart's and the London Hospitals.
Within 48 hours, I had an appointment.
Scans confirmed that the tumour was spreading into my neck and up towards
my temple.
Mr Hutchison explained it was life-threatening and that my chances of
survival would be greatly enhanced if the tumour was reduced before
surgery by chemotherapy. This would diminish the chances of small bits
breaking off during the operation and spreading elsewhere.
I was to have the chemotherapy over six months, then surgery. Mr Hutchison
sent me to a cancer specialist at University College Hospital, London. The
treatment was gruelling, but they did a great job in reducing the tumour.
When this was finished, my surgeon explained how he planned to replace
two-thirds of my jaw with a piece of living bone from my shoulder blade.
Though I realised this was a serious operation, I was more concerned about
how it might affect my golf swing, and that I would have no bottom teeth.
But then I remembered an article in Good Health about the dentist Andrew
Dawood, who had fitted a whole set of teeth implants in an hour.
I asked Mr Hutchison if he would be able to work with Mr Dawood during the
operation.
Otherwise, it would have taken months for my jaw to heal sufficiently even
for dentures. They agreed to work together.
I was warned the surgery would be long and complicated, and there was a
risk my face might be paralysed if any of the nerves were accidentally
damaged.
I had a scan at Mr Dawood's London dental practice. He created a 3D model
of my jaw which was used to plan my surgery. The operation took place last
June and took 12 hours.
Afterwards, I had a scar that ran from my chin, under my jaw and up to my
left temple.
I felt a bit sore, but was delighted teeth - operation requires with the
results. Apart from the scar, which people think is a shaving cut, I look
pretty much the same. Best of all, I can open and shut my mouth and bite
as well.
I was in hospital for fewer than three weeks, and a month after that I was
back on the golf course ? not bad going for someone who'd lost a chunk of
his shoulder blade. And I can even tuck into a steak after a game.
THE SURGEON
Iain Hutchison is an oral and maxillofacial surgeon at Bart's and the
Royal London Hospitals. He says:
Removing two-thirds of a cancerous jaw and giving someone a new jawbone
and set of teeth is challenging and complex - it was the first time such
an operation had been done.
It is a lengthy operation that requires stamina on the surgeon's part,
especially during the microscopic surgery, which involves joining up tiny
blood vessels to keep the bone graft alive. The key to treating this type
of bone tumour is to take it in two stages.
First, the patient needs chemotherapy to shrink it to a uniform shape,
where you can see all parts of the tumour when you operate and know there
are no stray tentacles left behind which could cause a recurrence.
Images of Barry's jaw were taken with a magnetic resonance imaging scanner
before and after the chemotherapy, to see the extent of the tumour, which
was the size of an orange.
Even after shrinking, it was still about 6cm long and extended from
Barry's jaw into his mouth.
It was stuck to the carotid artery and jugular vein in his neck, and
continued up towards his temple and the base of his skull and into his
throat.
Before operating, I was able to work out precisely how I was going to cut
the bone from Barry's shoulder blade using an exact resin model of his jaw
taken from a 3D computed tomography (CT) scan and printed on a 3D printer,
a special piece of equipment used by dentist Andrew Dawood.
Having the exact 3D model of Barry's jaw enabled the team to plan its
reconstruction accurately.
After Barry was given a general anaesthetic, I cut down the middle of his
lower lip through the chin, and then horizontally along his neck under the
jaw to in front of his left ear and up to his left temple.
I also had to ensure I had carefully moved out of the way the facial nerve
in the cheek - any damage could leave his face paralysed. This was done
using very fine scissors and forceps.
Then, using a scalpel, I teased away the carotid artery and jugular vein
supplying blood to the brain and held them aside.
Once I could access it, I cut the jawbone in half with an electric saw
just under the chin. Then I cut away the bone containing the tumour at the
back of the jaw.
Having removed this segment, the next stage was to insert a titanium plate
to support and fix the reconstruction in preparation for inserting the
bone taken from the shoulder blade.
We had been able to pre-bend the plate to the exact shape of the jaw's
outer surface using the 3D model. Previously, we have had to do this
freehand, which lengthens surgery by a couple of hours.
I then fixed the plate in place on the remaining piece of jaw with
titanium screws.
Replacing a cancerous jaw with the patient's bone is not unusual, although
it is technically difficult and arduous. We take bone from the shoulder
because it has the least impact on the patient.
I cut through the skin with a scalpel, and used an instrument which
cauterises the small blood vessels with an electric current to stop them
bleeding. Then, I raised skin and fat off the underlying muscle, and cut a
3cm by 10cm strip from the outer edge of the shoulder blade with a saw.
The shoulder blade bone was then removed, coated in muscle, fat and skin,
along with the single tiny artery and vein that provides it with blood and
keeps it alive.
These blood vessels - 2mm in diameter - had to be joined up to branches of
the carotid artery and jugular vein in Barry's neck.
This was done using a microscope, clamps, a micro-needle and microscopic
nylon stitches. It was vital these blood vessel junctions flowed well and
did not block or clot, otherwise the transplanted bone and skin would die.
Using the 3D template, I was able to shape the bone precisely to fit
Barry's jaw, and then screw it into the titanium plate.
After that, Andrew Dawood was able to begin drilling holes in the new
jawbone for titanium metal posts to hold temporary teeth in place. These
were good enough to last Barry several months until he had recovered
enough to have permanent teeth fitted.
The important part was to get the fixtures for holding the new teeth
screwed into place, because after surgery his jawbone would not have been
able to withstand the procedure for many months.
This is thought to be the first time a patient has had more than half
their jaw removed and has woken up with more teeth than they had before
the operation.
I had worked only in 2D before this operation and the ability to have the
exact 3D model in front of me helped improve accuracy.
It was also great for Barry to wake up and feel a normal set of teeth in
his mouth. His first words when he came round in intensive care were: 'My
bite feels different.' He didn't comment on the soreness of his shoulder
or the pain and swelling in his face and neck.
Working with Andrew Dawood and using his computer models was a great
example of crossfertilisation of skills and ideas.We now work together
regularly.
On the NHS, this operation would cost £50,000, plus £20,000 for the new
teeth. In a private hospital, the bill would be £85,000.
Iain Hutchison is founder of facial surgery research charity Saving Faces.
Tel: 020 7601 7582; www.savingfaces.co.uk
.
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